Chiropractic services may be considered medically necessary when all of the following criteria are met:
The member has a neuromusculoskeletal disorder; and
The medical necessity for treatment is clearly documented; and
Improvement is documented within the initial 4 weeks of chiropractic care.
Chiropractic manipulations may be considered medically necessary for individuals of 0-4 years old when all of the following criteria are met:
The member has a neuromusculoskeletal disorder related to the cervical region; and
The medical necessity for treatment of the cervical region is clearly documented; and
Improvement is documented within the initial 4 weeks of chiropractic care.
Chiropractic manipulations for individuals 0-4 years old with any other conditions is considered investigational.
If no improvement is documented within the initial 4 weeks, additional chiropractic treatment is considered not medically necessary unless the chiropractic treatment is modified.
If no improvement is documented within 30 days despite modification of chiropractic treatment, continued chiropractic treatment is considered not medically necessary.
Once the maximum therapeutic benefit has been achieved, continuing chiropractic care is considered not medically necessary.
Chiropractic manipulation in asymptomatic persons or in persons without an identifiable clinical condition is considered not medically necessary.
The fact that there is a symptom of «pain» is not sufficient to justify medical necessity. Misalignment of a peripheral joint or vertebral misalignment should be documented by X-rays and/or complete physical examination.
Manipulation is considered experimental or investigational when it is rendered for non-neuromusculoskeletal conditions (e.g., attention-deficit hyperactivity disorder, asthma, autism spectrum disorder, rheumatologic pain, depression, dizziness/vertigo, dysmenorrhea, epilepsy, female infertility, gastro-intestinal disorders, improvement of brain function, and menopause-associated vasomotor symptoms, muscular dystrophy, multiple sclerosis, pneumonia, and pulmonary emphysema; not an all-inclusive list) because its effectiveness for these indications is unproven.
Manipulation of infants is considered experimental and investigational for non-neuromusculoskeletal indications (e.g., infants with gastro-intestinal disorders including constipation, excessive intestinal gas, and gastroesophageal reflux disease).
Preventive manipulation services are not considered for payment, regardless of the age of the patient.
Chronic cases lasting more than 12 weeks and maintenance therapies are not considered for payment.
Only acute cases and exacerbations of chronic cases will be covered. The Acute Treatment (AT) modifier was developed to clearly define the difference between acute treatment and maintenance treatment and is required for reporting Chiropractic Manipulations.
An acute condition is considered when:
is a new complaint, lasting less than 4 weeks, evidenced by the date of X-rays or physical examination and when the interval between its first manipulation and the initial evaluation is relatively short or,
an acute exacerbation of a chronic condition.
It is expected that treatment by the chiropractor produces a substantial improvement in the patient’s condition.
The following conditions are not considered for payment:
• Acute fractures, dislocations, or old fractures with evidence of instability.
• Neoplasms that involve the spinal column.
• Infections in the spine that involve the bones or joints.
• The presence of an aneurysm near an area for manipulation.
• Critical conditions
X-rays by chiropractors:
There is an approved policy by Triple-S authorizing the offering of benefits in accordance with the request of Cost-Plus groups or biddings.
The law that regulates the practice of chiropractic in Puerto Rico in its Chapter 7, Paragraph 158 (License-Power Conferred) Letter A indicates the following:
Examine and analyze the human body through the use of physical, chemical, electrical, thermal, or ionic radius methods, as well as through the use of X-rays and other imaging studies as the law dictates.
To bill X-rays services, the chiropractor must have the Radiological Health Certification.
X-ray services are covered as long as they are ordered by a physician surgeon or chiropractor as established in the coverage.
The following services are not considered for payment to chiropractors.
• Laboratory analysis
• Injection
• Medications
• EKG
• Acupuncture
• Nutritional Supplements
• Orthopedic devices
